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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:48:04 PM


Document Has Been Signed on 12/05/2023 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:A1 DEL MONTE STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR:RODRIGUES, JUDYFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:158CENSUS: 143DATE:
12/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lucky KaurTIME COMPLETED:
04:00 PM
NARRATIVE
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On 12-5-23 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding facility’s plan of operation. LPA met with assistant executive director Lucky Kaur and explained the purpose of the visit. LPA reviewed current plan of operation on file with the department as well as facility’s theft and loss policy. It was determined through record review and interviews related to complaint # 27-AS-20230825145223, that licensee currently holds debit cards for eight (8) residents in care. It was further revealed through record reviews and interviews that all residents and applicable responsible parties have signed and agreed to safeguard agreement allowing licensee to manage debit cards and withdraw funds on behalf of residents, however, such a procedure has not been included in the facility’s plan of operation currently on file with the Department.

As a result of today’s case management, citations are issued under Title 22, Division 6. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/05/2023 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: A1 DEL MONTE STOCKTON
FACILITY NUMBER: 392700993

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
87208(a)(9)

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Plan of Operation. (a) Each facility shall have and maintain a current, written definitive plan of operation… Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval…(9) A statement whether or not the applicant will handle residents' money and/or valuables. If money or valuables will be handled, the method for safeguarding…This requirement is not met as evidenced by:
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Licensee will ensure an updated plan of operation be submitted to LPA by POC due date to include, but not be limited to: Policies on safeguarding resident properties including debit cards and how such cards are stored and utilized.
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Based on record reviews and interviews, licensee did not ensure the practice and method of maintaining and using resident debit card for purposes of obtaining monthly rent be explained in the facility’s plan of operation which resulted in a potential health, safety, and resident rights risk to residents in care.

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Type B
12/15/2023
Section Cited
CCR87405(d)(2)

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Administrator - Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)… (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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Administrator will read regulation 87405(d)(2) and reference regulation 87208(a). Administrator will submit a signed declaration of understanding these regulations to LPA by POC due date.
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Based on record review, Administrator did not exercise the practice of initiating a necessary change in plan of operation and submit to the Department. This resulted in a potential health, safety, and resident rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2